Infantile Diarrhea 婴 幼 儿 腹 泻

1. Infantile Diarrhea婴 幼 儿 腹 泻 Department of Pediatric, West China Second University Hospital, Sichuan University 四川大学华西第二医院--儿科 XIE Yong-Mei (谢咏梅)

2. Definition and classification of infantile diarrhea (定义与分型) Definition • Increases in fluidity, volume and number of stools. • Multiple pathogens and complex origins. • High incidence during age of 6 months to 2 years Classifications • Acute < 2 weeks • Chronic > 2 months • Persisting 2weeks ~ 2 months

3. Predisposing factor (易感因素) • Underdevelopment of GI system • poor function and low digestive enzyme • heavy digestive burden • Underdevelopment of immune system • systemic immunity : low immunoglobulin • local immunity of GI: low SIgA

4. Cause of infantile diarrhea Ⅰ-- infection (病因Ⅰ) • Intra-enteric infection ①Virus: rotavirus, norwalk virus, coronavirus ②bacteria: escherichia coli (E . Coli) • invasive: EPEC, ETEC • non-invasive: EIEC, EGEC ③others: fungus, tuberculosis, parasites • Extra-enteric infection: symptomatic diarrhea

5. Cause of infantile diarrhea Ⅱ-- noninfectious (病因Ⅱ) • Inappropriate feeding : • inappropriate supplementary food: dietary diarrhea • deficiency of disaccharidase, lactose intolerance • allergic cause: • food allergy (induced by IgE) • food intolerance (induced by IgG) • weather • cold→gastrointestinal movement ↑ • hot → thirsty → overeating, dyspepsia

6. Pathomechanism of infantile diarrhea Types according to pathophysiology： • osmotic diarrhea(渗透性): hyperosmosis in intestinal tract (eg. lactose intolerance) • secretary diarrhea(分泌性): increased secretion of intestinal juice( eg. Zollinger-Ellison Syndrome) • exudative diarrhea(渗出性)： Inflammatory exudate of intestines (eg.infectious diarrhea) • dynamic diarrhea(动力性): enhancement of intestinal motility(eg.irritable bowel syndrome) Causes are usually not single but compound for each patient

7. Pathogenesis of noninfectious diarrhea

8. Bacterial colonization toxins LT or ST Ganglioside GM1 receptor Toxin LT Toxin ST Adenylcyclase guanylcyclase ATP cAMP GTP cGMP Electrolytesand water, absorption↓secretion↑ Secretary diarrhea Watery stools, little mucosa Pathogenesis of infectious diarrhea 1. non-invasive bacteria (非侵袭性) , enterotoxin

9. mucous hyperemia, edema, Exudation, ulcer, hemorrhage small intestine colon Direct invasion intestinal wall exudative diarrhea bloody pus stools rectal tenesmus RBC, WBC, pus cell , phagocyte in stools Pathogenesis of infectious diarrhea 2. invasive bacteria(侵袭性)

10. Rotavirus replication injury and necrosis of enterocyte Dysfunction of digestion and absorption deficiency of disaccharidase Decomposition of lactose ↓ short chain organic acid ↑ intestinal osmotic pressure ↑ plasma and Interstitial fluid Permeate into intestin osmotic diarrhea watery stools，like egg soup Pathogenesis of infectious diarrhea 3. Virus infection (病毒)

11. Clinical manifestations of infantile diarrhea ( 临床表现) Dehydrationelectrolyte disturbances Disorder of acid base Extraenteric Systemic Symptoms Gastrointestinal symptoms infective toxic symptoms Fever, depress toxic encephalopathy MORDS Dehydration, shock electrolyte disturbances metabolic acidosis metabolic disorder Diarrhea, vomiting abdominal pain change of stool

12. Assessment of dehydration and electrolyte disturbances • Excessive loss of water and electrolyte, especially loss of extracellular fluid Dehydration of infants: easy, severe, develop soon and recover soon

13. Assessment of dehydration

14. Danger signs of dehydration

16. Types of dehydration according to osmotic pressure (sodium level) of plasma

17. Diagnosis of infantile diarrhea (诊断) Establish diagnosis is not difficult According to clinical symptoms and physical signs stool changing and laboratory examination Assessment is more important dehydration degree type disturbance electrolytes acid-base cause infection non-infectious

18. Differential diagnosis (鉴别诊断) No or few WBC in stools • Physiological diarrhea: breast feeding with normal growth • Disorder of digestion: lactose intolerance, food allergy • Symptomatic Diarrhea: pneumonia Abundant WBC and RBC in stools • Dysentery : invasive salmonella typhimurium • NEC (Necrotizing enterocolitis) • Secondary intestinal intussusception • Inflammatory bowel disease

19. Principle of Treatment (治疗原则) • Reasonable Diet • Antibiotic treatment • Intensive nursing care • Liquid therapy • Symptomatic treatment

20. Feeding during diarrhea (喂养) • Continue feeding child • Give as much as child want • Give small frequent feeds • Encourage anorexic child to eat • Rotavirus gastroenteritis and lactose intolerance: diarrhea milk powder (Lactose-free formula) • Food allergy: amino acid milk powder

21. Antibiotic treatment (抗生素选择) • Indication for antibiotic using • newborn or weak infant with severe complications • invasive bacteria infection: pus and blood stool, infective toxic symptoms • Chose of antibiotic • according to possible pathogen: G- or G+ • according to bacterial culture and drug sensitivity test

22. Fluid replacement (补液治疗) • ORS (Oral rehydration salts) • WHO recommended • preferred treatment for mild to moderate dehydration • Prevent for losses of fluid and electrolyte • Vein fluid replacement • Severely dehydrated • shock must receive immediate and aggressive intravenous fluid therapy

23. ORS (口服补液盐) • osmotic pressure ：2/3 tonic • preferred for mild to moderate dehydration • mild dehydration 50~80ml/kg • moderate dehydration 80~100ml/kg • prevention dehydration 50ml/kg, small frequent oral • supply physiological maintenance and ongoing loss of fliud and electrolytes : slowly replace within 12~16 hours, should dilute to 1/3 tonic

24. Two ways of giving ORS Gastric tube Oral

25. Intravenous fluid therapy (静脉补液) • Severe dehydration • Shock must receive immediate and aggressive intravenous fluid therapy • Three part of total supplement • Complete correcting of the deficit of past loss • Replacing ongoing loss of water and electrolytes • Supply the physiological maintenance

26. Common solution of liquid therapy (常用液体) • Nonelectrolyte solution: • Glucose: 5%GS or 10%GS, tonic is zero • Electrolyte solution : • NaCl (NS): 0.9%NaCl (1 tonic) and 10%NaCl • NaHCO3: 5%NaHCO3 and 1.4%NaHCO3 (1 tonic) • KCl: 10%KCl • CaGS: 10% calcium gluconate

27. Configuration of different tonic solution

28. Principle of intravenous rehydration(补液原则) 三定三先三见 • three determination • ① qualitation (tonic)；② quantification；③ speed • three priority • ① fast to slowly；② hypertonic to hypotonic；③ NS to glucose • three observation • ① urine for KCl； ② convulsion for CaGS； ③ acidosis for NaHCO3

29. The first day intravenous transfusion(1) • Quantification(定量): total volume = past loss + ongoing loss + physiological maintenance • mild degree of dehydration 9 0~120ml/kg • moderate degree of dehydration 120-150ml/kg • severe degree of dehydration 150-180ml/kg • Qualitation(定性) : average tonic of all fluid • isotonic dehydration 1/2tonic solution • hypertonic dehydration 1/3 tonic solution • hypotonic dehydration 2/3 tonic solution

30. The first day intravenous transfusion(2) • Speed (fast to slow; hypertonic to hypotonic) • Rapid rehydration stage: shock patient, 2:1 isotonic fluid, 20ml/kg, within 30-60 min • Replacement for past losing: give half of total dose within 8-12 hr, 1/2 ~1/3 tonic, 8~10ml/kg.h • maintain rehydration stage: finish the remnant doses (ongoing loss and physiological maintenance) within 12-16 hr, 1/3 ~1/4 tonic, 5ml/kg.h

31. Summary for the first day transfusion

32. The second day rehydration • Evaluate effects of treatment • Assess degree of dehydration again • If relief, change intravenous transfusion into ORS

33. Treatment for electrolyte disturbances--hypokalaemia, hypocalcemia • Kalium supplement • See urine supply Kalium: severe dehydration with on urine, KCl is forbidden • physiological requirements: 10%KCl 2-3ml/kg.d • Calcium supplement • Convulsion: indicate possible of hypocalcemia • 10%CaGS 0.5~1ml/kg/time, slowly ivgtt

34. Treatment of metabolic acidosis (纠正酸中毒) • Mild and moderate degree of acidosis • can self-corrected once dehydration corrected and effective circulation volume restored • Severe acidosis • should use NaHCO3 according to analysis of arterial blood gas ( ABG) • For full correction of acidosis, NaHCO3 required (mmol)= Base deficit x body weight x 0.3, the first dose usually give half dose of total

35. symptomatic treatment (对症治疗) Common drugs used in diarrhea • Micro-ecological therapy: probiotics, prebiotics and synbiotics • lactobacilli • Bifidobacteria • Antidiarrheal agents • Adsorbents: SMECTA • Inhibit secretion of intestine: racecadotril granules • Mucous membrane protectors 

36. Eliminating etiology: bacterial culture and drug sensitivity test, enteroscope • Adjusting diet: lactose-free formula and amino acid milk powder • Careful using antibiotics: secondary infection of fungus • Micro-ecological therapy: probiotics, prebiotics and synbiotics Principle for treatment of chronic diarrhea

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